1. Breast Clinical Correlation
Anne T. Mancino MD

2. Breast Cancer Facts
An estimated 178,000 new cases of female invasive breast cancer will be diagnosed
An estimated 43,500 women will die from breast cancer
Approximately 37,000 cases of female in situ breast cancer will be diagnosed
American Cancer Society 1999 Cancer Facts & Figures

3. Risk Factors for Breast Cancer
Age
Personal history % per year risk new cancer
Family history
First degree relative
Pre-menopausal  risk 3-4 fold
Germline mutation (BRCA1/2) 60-85% risk
Previous biopsy, especially with atypia
Early menses, late menopause, parity

4. ACS Screening Guidelines
Screening Mammography
Yearly starting at age 40
Clinical Breast Exam
Every 3 years age 20-39
Yearly after age 40
Breast Self Exam
monthly after age 20

5. Breast Exam: Anatomy Variety of sizes and shapes
Composed of fatty, fibrous and glandular tissue
Lymph nodes are important

6. Accessory Breast Tissue
Should always be examined as carefully as the other breast tissue.

7. Physical Findings Suspicious for Malignancy
Venous patterns
Skin edema
Nipple inversion
Retraction
Scaling or ulceration of the nipple
Inflammation

8. Venous Patterns
Increased prominence or engorgement of blood vessels in an asymmetric patterns
Suggestive of angiogenesis of tumor

9. Skin Edema Produced by lymphatic blockade by tumor, lymph node removal
Appears as thickened skin with enlarged pores
aka “peau d’orange”

10. Nipple Inversion Can be a normal variant Unilateral or bilateral
Be suspicious for cancer in recently developed cases

11. Retraction Can be caused by fibrosis formation in breast cancer
Fibrosis may produce retraction signs:
Dimpling of skin
Alteration in breast contour
Flattening or deviation of nipple

12. Retraction As Seen on Mammogram

13. Scaling or Ulceration
Seen in nipple and/or areola
“Paget’s disease”

14. Paget’s Disease
Tumor cells in epidermis

15. Inflammation - Breast Abscess
need to distinguish from inflammatory breast cancer
needs incision and drainage

16. Inflammatory Cancer no discrete mass erythema and warmth
cutaneous lymphedema
obstruction of dermal lymphatics by tumor

17. Inflammatory Cancer

18. Nipple Discharge Spontaneous Unilateral One Duct
Clear, Serous, Bloody or Serosanguinous
Green
White or Milky

19. Nipple Discharge
Milky, clear, green, grey or black appearing discharge is usually physiologic
Referral not normally necessary, especially if bilateral or multiple ducts

20. Nipple Discharge Bloody discharge
Could be a sign of benign intraductal papilloma
Should always be a referral to a breast specialist

21. Intraductal Papilloma
Most common cause of bloody nipple discharge
papilla have central fibrovascular core covered by myoepithelial and epithelial cell layers

22. Nipple Discharge
Serous drainage could be a sign of duct ectasia

23. Palpable mass Ultrasound to see if solid or cystic
Guide aspiration or biopsy

24. Cysts Derived from terminal duct lobular unit endothelial lined
no risk of cancer

25. Fibroadenoma
Well circumscribed
occur in younger women

26. Fibroadenoma Well circumscribed benign stromal and epithelial elements
no increased risk of cancer

27. Biopsy Techniques Fine Needle Aspiration Cytology vs. Histology
Significant insufficient sampling
Unable to differentiate in-situ from invasive

28. Examples of Ductal Cells Under a Microscope
BENIGN
MALIGNANT

29. Tru-Cut Histology More definitive compared to FNA
Small fragmented samples
Multiple insertions/re-insertion's

30. Vacuum-Assisted Mammotome
Histology
Large, contiguous tissue samples
Single insertion
Can mark biopsy site
2-3 mm skin incision – sutureless

31. Core biopsy samples

32. Screening Mammogram Can identify abnormal mass or calcification
Biopsy under mammogram guidance
Stereotactic biopsy or excisional biopsy guided by wire placement

33. Stereotactic Breast Biopsy

34. Calcifications

35. Intraductal Hyperplasia
No atypia
proliferation of epithelial cells
varied size,shape
elongated secondary spaces
low risk cancer

36. Atypical Ductal Hyperplasia
Uniform cells with monotonous nuclei
lacks some features of DCIS -near periphery maintain orientation
three to five-fold increase risk of breast cancer

37. Lobular Carcinoma in Situ (LCIS)
Acini of lobules filled with uniform tumor cells
Multicentric and bilateral
1% per year risk of invasive cancer in either breast

38. Ductal Carcinoma in Situ (DCIS)
Comedo type - central necrosis
Other types:
cribiform
micropapillary
papillary
solid

39. Infiltrating Ductal Cancer
most common type
well (gr I) to poorly (gr III) differentiated
Gr I tumor cells grow in glandular patterns
prognostic factors:
ER,PR, HER-2neu,p53
S-phase, ploidy
angiogenesis

40. Open Surgical Excision
Performed in the OR
large skin incision
Local or General Anesthesia

41. History of Treatment 1890’s - Halstead - Radical Mastectomy
Dyson and Patey - Modified Radical Mastectomy
McWhirter - Simple Mastectomy and radiation therapy
1990’s - Lumpectomy/Axillary node dissection and radiation therapy

42. Radical Mastectomy
Remove breast, axillary contents, pectoralis muscles
lymphedema of left arm

43. Axillary Node Dissection
Level I - lower axilla around tail of breast
Level II - nodes up to the axillary vein
Level III - nodes above axillary vein and under pectoralis

44. Modified Radical Mastectomy
Excision of nipple and areola
breast and axillary nodes
leave pectoralis muscles

45. Modified Radical Mastectomy
Axilla dissected en bloc with the breast

46. Modified Radical Mastectomy
Long Thoracic Nerve
Winged Scapula
Thoracodorsal Nerve
Intercostal brachial
Numbness of the upper inner arm

47. Lymphatics
Routes of lymphatic flow
Used to devise less invasive techniques

48. Sentinel Node Biopsy Technetium sulfur colloid Isosulfan blue
injected at tumor
draining lymph node identified

49. Sentinel Node Biopsy
Node identified using gamma probe or by tracing blue lymphatic
excise “hot” and/or blue nodes and any palpable nodes

50. Sentinel Node Biopsy Node sent to pathology
if no tumor, may avoid axillary dissection
false negative rate is 1-2%

51. Skin-sparing Mastectomy
Still excise nipple and areola

52. Skin-sparing Mastectomy
Leaves adequate skin for immediate reconstruction

53. Reconstruction
tissue expander (R) placed initially - inflated with saline
subpectoral placement
silicone implant

54. Breast Cancer Typically Develops Over A Long Period of Time
Most breast cancer begins in the milk ductal system, and develops over years.
Screening aims at detection of cancer at early stage